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Petri Virtanen · Jari Stenvall

Intelligent
Health
Policy
Theory, Concept and Practice
Intelligent Health Policy
Petri Virtanen • Jari Stenvall

Intelligent Health Policy

Theory, Concept and Practice
Petri Virtanen Jari Stenvall
The Finnish Innovation Fund SITRA School of Management
Helsinki, Finland University of Tampere
Tampere, Finland

ISBN 978-3-319-69595-2 ISBN 978-3-319-69596-9 (eBook)

https://doi.org/10.1007/978-3-319-69596-9

Library of Congress Control Number: 2017957622

© Springer International Publishing AG 2018

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Preface

Health matters to everyone. It is an essential ingredient in our lives. If you do not

have good or adequate health, you most likely suffer somehow in your life. Good
health promotes your activities in life and brings you happiness and good spirit.
This is why we have chosen health as a policy subject in this book.
Moreover, public policies and organisations are important—or, to be more
precise, essential. Every one of us is affected by public policies and uses the
services provided by public, private or non-governmental organisations.
In this book, we have combined these important topics—health, public policy and
organisations—and written about health policy from a perspective that we consider
to be novel. Throughout this book, we maintain that the future of health policies and
healthcare service delivery pretty much depends on how intelligently they are
planned, implemented and evaluated. In our thinking, public policy constitutes a
learning cycle that aims at the betterment of the society. Intelligence is an important
ingredient, based on client-centred thinking, systematic data-driven leadership
mechanisms and good leadership, for future health policies and services—and
service ecosystems.
We approach public health policy from a comprehensive public policy viewpoint.
In doing so, we deliberately focus on healthcare organisations as they exist in the
current and future service space by not making a distinction between the roles of the
service purchaser and the service producer. If we had decided to include this topic,
the manuscript would have been twice as long. Other interesting and important
topics are also out of reach of this manuscript for the same reason—topics such as
democracy issues and topics related to co-creation models at the public policy level.
A word of warning. We are not trained doctors or representatives of any
healthcare profession. We have written this book as public governance, public
policy and public administration experts and enthusiasts with a joint professional
and academic track record on these topics totalling more than 50 years.
This is our fifth book together along with numerous academic and semi-academic
papers written together over the last 15 years. With regard to monographs, we have
previously written about change leadership (published in 2007), public sector

v
vi Preface

leadership (2010), development models in health and social services (2012) and
intelligent public organisation (2014). There are also numerous spin-off academic
and semi-academic articles from our books.
Without exception, our writing missions have been a great fun, and this has been
the case with this book as well. For us, the writing process is fun when we learn
something together. Parts of this book have been written in Finland, our home
country, and also in China, the Netherlands, Qatar, Indonesia, the USA, the United
Arab Emirates, the UK and Singapore.
Finally, Petri wants to thank Johanna for her love, understanding and patience
during the writing process of this book. Jari is deeply thankful to Kirsi for her
all-encompassing support and love over the years.

Helsinki, Finland Petri Virtanen

Tampere, Finland Jari Stenvall
September 2017
Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 A Quest for Well-Being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Why Does Intelligence Matter? . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Intelligence and Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.4 The Concept of Organisational Intelligence . . . . . . . . . . . . . . . . . 6
1.5 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2 Systemic Governance Challenges and Well-Being . . . . . . . . . . . . . . 15
2.1 The Evolution from Health to Well-Being . . . . . . . . . . . . . . . . . . 15
2.2 Elusive Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.3 Technology Revolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.4 Digitalised Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.5 Reforms and Intelligent Health Policy . . . . . . . . . . . . . . . . . . . . . 29
2.6 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3 Intelligence in Public Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.1 Health and Public Policy: The Contents and the Actors . . . . . . . . 41
3.2 Easton’s Public Policy System Revisited . . . . . . . . . . . . . . . . . . . 44
3.3 Public Policy Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
3.4 A Pragmatic Approach to Public Policy? . . . . . . . . . . . . . . . . . . . 49
3.5 Adaptive Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.6 Complex Public Policy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.7 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
4 Knowledge Management and the New Configurations of Health
Markets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.1 The Nexus Between Complex Society, Complexity Science
and Complex Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

vii
viii Contents

4.2 How Rational Is Public Policy Decision-Making? . . . . . . . . . . . . 69

4.3 Public Policies and Alternative Truths Have Been Siblings
for Ages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
4.4 The Changing Landscape of Knowledge in the Field of Health . . . 74
4.5 Sense-Making in Health Policy and Healthcare Organisations . . . . 78
4.6 Digitalisation, Health and Organisational Knowledge . . . . . . . . . . 81
4.7 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
5 Intelligent Healthcare Organisations and Patient-Dominant Logic
in the New Service Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
5.1 From the Iron Cage of Bureaucracy to the Isomorphic
Change of Organisations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
5.2 Enter Service Science and Service-Dominant Logic . . . . . . . . . . . 93
5.3 Service Space, Patient-Dominant Logic and Technology . . . . . . . 99
5.4 Street-Level Intelligence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5.5 Intelligent Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.6 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6 Leadership and Human Resource Management . . . . . . . . . . . . . . . . 117
6.1 Intelligent People in Organisations . . . . . . . . . . . . . . . . . . . . . . . 117
6.2 Robots and Big Data Take Over? . . . . . . . . . . . . . . . . . . . . . . . . 119
6.3 The Selection of Leadership Perspectives . . . . . . . . . . . . . . . . . . 120
6.4 Strategic Human Resource Management . . . . . . . . . . . . . . . . . . . 121
6.5 Trust Constitutes Work Community . . . . . . . . . . . . . . . . . . . . . . 126
6.6 Leaders and Employees Intertwined by Communication . . . . . . . . 128
6.7 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
7 Intelligent Evaluation and Performance Measurement in Public
Health Policy and Public Service Systems . . . . . . . . . . . . . . . . . . . . . 135
7.1 Are Public Healthcare Organisations Immortal? . . . . . . . . . . . . . . 136
7.2 The Links Between Accountability, Performance Measurement
and Policy Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
7.3 The Composition of Intelligence in Policy Evaluation . . . . . . . . . 142
7.4 Accountabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
7.5 The Key Concepts and Timescales of Intelligent Policy
Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.6 The World of Performance Evaluation Is Not Without Problems . . . 159
7.7 Engineering Logic of Performance Measurement Is Passé . . . . . . . 163
7.8 Hard Facts, Dangerous Half-Truths or Total Nonsense? . . . . . . . . 166
7.9 Synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Contents ix

8 The Fundaments of Intelligence in the Future Health Policy . . . . . . 177

8.1 Contextual Fundaments of Policy Intelligence . . . . . . . . . . . . . . . 177
8.2 Conceptual Fundaments of Policy Intelligence . . . . . . . . . . . . . . . 181
8.3 Service-Related Fundaments of Policy Intelligence . . . . . . . . . . . 183
8.4 Leadership-Related Fundaments of Policy Intelligence . . . . . . . . . 186
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Chapter 1
Introduction

Abstract Generally speaking, the basic topics of organisation theories have not
changed much over the decades. Finding a balance between the rational and
non-rational elements of human behaviour is still a cardinal issue of modern life,
society and thinking. The basic question is how to best coordinate human activities
in order to make up a highly rational unit and, at the same time, maintain social
integration, the normative commitments of participants and their motivation to
participate. This is one of the key questions in intelligent organisations as well.
Comprehensive models of organisational intelligence, which bring together rele-
vant assumptions and concepts, are lacking in literature. For this reason, the
purpose of this chapter is to present an integrative approach to organisational
intelligence research. We emphasise that organisations need intelligence if they
want to find ways to survive in complex environments. Our starting point is that
healthcare organisations can learn from the literature on organisational intelligence.

1.1 A Quest for Well-Being

The city of Hämeenlinna is a small city with 70,000 habitants near to Helsinki in
Finland. Hence, it has been one of the prime movers in developing healthcare in the
Nordic countries. The city has reformed its healthcare system over the last 10 years.
The turning point was the insight that there was a need for a paradigm change in the
healthcare system. It required service users to have a stronger position in the service
system. They are more and more capable to evaluate and take responsibility for
health-related issues by themselves. Hence, there are service users who need a lot of
services as well. For this reason, Hämeenlinna established the so-called channel
model for the most demanding service users. Technology constantly gives new
possibilities in developing health services. Healthcare professionals’ attitudes,
competencies and working methods should change in the new environments.
Hämeenlinna has moved towards the paradigm of health intelligence. This is a
comprehensive approach for developing health policy with service users and using
new technological possibilities. Developing health-intelligent policy is a process.
The content and methods of health policy change all the time.
The city of Hämeenlinna is not alone. Many countries—like Finland, the UK and
the Netherlands—have faced significant challenges that concern healthcare systems

© Springer International Publishing AG 2018 1

P. Virtanen, J. Stenvall, Intelligent Health Policy,
https://doi.org/10.1007/978-3-319-69596-9_1
2 1 Introduction

and services. Healthcare systems and policies are under considerable strain owing
to population ageing, fiscal consolidation, migration, increasing inequality and both
Europeanisation and globalisation. Here, decision-makers face a quandary: how can
one constrain healthcare spending and yet satisfy public demands in the health
system? The question is how to outline and implement healthcare policy, how
organisations operate, how they are managed and how to provide services for
service users. The welfare-state crisis means discussions on how to maintain—if
it is possible to maintain—welfare in society.
In the context of health policy, new kinds of intelligent technologies have been
considered as solutions for reinventing health policy. The European Union has, for
instance, put forward a digital agenda to improve every citizen’s health by making
health data available to everyone using eHealth tools. However, eHealth is only one
issue on the digitalisation agenda. All sociotechnical systems operate on a technical
base. This means that email, chat, bulletin boards, blogs, Wikipedia, eBay, Twitter,
Facebook, YouTube and other health-related sensors, apps and web services are all
sociotechnical systems, which millions of people use. The question, then, is how do
these systems affect health and shape the way we understand, experience, develop
and maintain our health?
Given the transformational change in the field of health, policy instruments need
to be mobilised in order to make sustainable and health promotion-based changes in
people’s way of life, well-being and health, both experience- and diagnosis-based.
Health policies ought to be more coherent (between policy areas, taking into
account the emergence of nexus policy problems), evidence-based and intelligent.
Digitalisation plays an important role in how traditional concepts of health and
well-being are currently changing. The role of the individual in the process of
sustaining health and enhancing well-being plays a crucial role here as well.
The contribution of this book is to note that austerity, personalisation and service
integration are driving the new governances of services beyond interorganisational
coordination into more closely coupled service systems in which service users
(as co-producers) play an active role. In this book, what we seek here is a better
understanding of the intelligence in public health policies, healthcare organisations
and healthcare service systems. We also want to show why contemporary public
policy making, leadership and planning within the field of health should be replaced
and with what.

1.2 Why Does Intelligence Matter?

In this book, our approach is to link the concept of intelligence with public health
policy and healthcare organisations. At the outset, we think that nobody wants to be
silly or dumb, nor do we think that anybody would want to work in a ridiculous,
moronic or stupid organisation. People don’t want to use their time to implement a
useless policy that is so stupid that it does not help people. The fact is that not only
human beings but also organisations or even the system of policy making can be
1.3 Intelligence and Health Policy 3

intelligent or stupid. In some cases, intelligent people might even make stupid
decisions due to their working environment.
In recent years, researchers have increasingly started to talk about requirements
for more intelligence in public activities and public administration and generally
about more intelligent service interventions and service ecosystems (Stenvall and
Virtanen 2015; Virtanen and Vakkuri 2015). This kind of discussion tells us that it
is possible to increase intelligence in organisations, policy making as well as
implementation. There are technological possibilities to develop organisational
intelligence.
There are many books about intelligence and many more about health policy.
Without a doubt, intelligence is a popular topic in management and organisational
research and attracts many researchers and practitioners from different fields
(Akgün et al. 2007). In the organisational and policy context, it is possible to
approach intelligence, as an example, from the perspective of professions (Abbott
1988), teams (Hackman 2011), key persons’ retention to organisation (Goffee and
Jones 2009) and policy making (Lindblom 1965). The literature on public policy
includes little discussion on the relationship between policy and intelligence.
Although the term intelligence is quite unknown in public policy literature, there
are a lot of themes that are relevant for us. One of the traditional discussion topics is
what the relationship between politicians and experts in policy making and imple-
mentation is. This is related to the discussion raised by Max Weber (1978). We can
ask what makes administrative systems and actions rational. There is a lot of
discussion on evidence-based policy in the literature. It is public policy informed
by a rigorously established objective (Head 2008). Learning is also an important
aspect in intelligence-led public policy (Hall 1993).
The essential purpose of this book is to clarify the conceptual relationship
between public policy and intelligence in the context of health. This requires both
practical examples on health policy and theoretical discussions. We agree with Guy
Peters’s (2015) argument that public policy must strike a balance between aca-
demic, theory-driven work and the practitioner-oriented, real world of public
policy.
There is a lack of coherent studies that put together the system perspective,
intelligence and health policy. Our intellectual goal in this book is to cover this
pitfall by making explicit the organisational activities that generate organisational
intelligence within health policy. This is a challenging task because there are many
forms and levels of intelligence.

1.3 Intelligence and Health Policy

It is reasonable to raise the question of why intelligence is a relevant issue in health

policy. Why should organisations be intelligent in the health system? One of the
main arguments for why intelligence is an important aspect can be seen in the
findings of studies which show that intelligent organisations and policy making are
4 1 Introduction

more successful than so-called non-intelligent organisations and policy making

(cf. Matheson and Matheson 2001; Virtanen and Stenvall 2014).
There are several definitions of public policy. For instance, Gerston (2015)
defines public policy as the combination of basic decisions, commitments and
actions made by those who hold or have an influence on government positions of
authority. In general, public policy includes which policy ideas are embedded and
the basis on which policies are framed, articulated and implemented (Hall 1993;
Peters 2015). In a broader sense, public policy can be described as the overall
framework within which government actions are undertaken to achieve public
goals. The framework of public policy covers policy objectives, policy instruments,
government’s implementation structure and implications for reform. Public poli-
cies—like health policy—are filtered through a specific policy process, adopted and
implemented through laws, regulatory measures, courses of government action and
funding priorities and are enforced by a public agency.
Actors, practices and processes either make or do not make public policy
intelligent. In this book, health policy intelligence is understood as the capability
of health policy actors to bring about the outcomes they desire—both internally and
in the environment.
This leads to the following definition:
In our approach, the intelligence of health policy relates to better deployment of knowledge
in planning and supervising service production, better involvement of co-creation mecha-
nisms in developing healthcare services and better evaluation of health policies. Overall,
intelligence in the domain of health policy involves better adaptiveness and change
management as drivers for organisational change.

There are several factors that are the cornerstones of intelligent health policy.
First, intelligent public policy is related to the discussion on how to use expertise or
evidence in public policy. Intelligence as a part of policy making means wisely
managing in a complex environment. In this context, different kinds of think tanks
can produce better policy making by creating new ideas for policy making.
According to Sanderson (2009), intelligent policy making rests on two pillars:
our developing knowledge about complexity and ideas from a pragmatist philo-
sophical position. He argues that, at the heart of intelligent policy making, people
should be committed to experimentation and learning.
Second, the cornerstones of intelligent health policy are precise and ambitious
objectives. Intelligent policy making means that the actors of policy making have
the ability to identify weak signals from the environment and the factors of change
in the operating environment. They have a better capacity to change, and they
utilise resources better than non-intelligent organisations (Virtanen and Stenvall
2014). Intelligence means the capacity to manage complex and constantly changing
environments.
Public policies interact with their environments. In this context, health policy
and service systems appear to become even more complex. Intelligence is necessary
due to, for instance, ongoing changes, increasing complexity and technological
development. The number of actors involved in the formulation, implementation
1.3 Intelligence and Health Policy 5

and evaluation of health policy continues to expand, which means that the full
calibre of all traditional policy instruments (i.e. regulation, financial resources and
information) should be mobilised.
The need to be innovative in the design architectures, service designs and the
implementation of health policy calls for new adaptive capacities in organisations
in the field of health. Health service systems appear to have become even more
complex. Even the service users’ life situations are much more complex, which
emphasises new kinds of service-delivery systems and practices like co-production
(Tuurnas 2016). Intelligence in health policies means better and more qualitative
services for service users.
In Table 1.1, we have summarised the main components of intelligent health
policy.
Without a doubt—as Travica (2015) has noted—intelligence produces several
necessary outcomes for organisations. An intelligent organisation is capable of
making the right decisions. Intelligence can produce the capabilities of creating
successful and innovative products, impacting the environment and mobilising
creative people and other resources.
In this book, we focus our attention on intelligence and intelligent solutions
within health policy, especially within comprehensive health policy. This means
that we pay attention to the value of health and intelligence at the levels of both
policy and the service users.
Summarising our viewpoints, intelligence can be considered a potential pathway
for developed health policy. In practice, policies create the context for intelligence.
Intelligence in health policy and health services interacts at various interfaces and
levels within organisations in relation to political decision-making, service users
and cooperating partners. The demand for intelligence involves all aspects of an
operation.

Table 1.1 The main proponents of intelligence in health policy

The role of knowledge creation and
deployment in decision-making
The role of patient involvement in
service development
The role of evaluation
The role of management changes
The role of technology
The role of healthcare professionals
The role of quality of healthcare
services
Non-intelligent health
policy Intelligent health policy
Sporadic A mechanism for constant
strategic insight
Co-production Co-creation
Ex post, looking for Ex ante and ex nunc, looking
scapegoats for betterment in services
Reactional Built-in adaptivity to change
A threat or innovation A mechanism for change
imposed from
environment
Dominant Co-creation tribes
Organisational secret Based on open data, a
mechanism to improve
6 1 Introduction

1.4 The Concept of Organisational Intelligence

There exists a plethora of research literature on intelligence and healthcare organi-

sations related to knowledge creation, leadership, the role of the patients and
technology. Hence, there is not just one practice—like good leadership and pro-
cesses—that produces organisational intelligence. Actually, organisational intelli-
gence is a comprehensive phenomenon (Stenvall and Virtanen 2015). Our
conclusion is that the research literature that is missing at the moment is, in fact,
those that combine the above-mentioned elements. This book tries to fill this gap in
the research literature.
In this book, our starting point is—like Wilensky (1967) and March (1991) have
noted—that organisational intelligence is the key element in complex systems and
environments. At an organisational level, intelligence is understood as the capabil-
ity of an organisation to bring about the outcomes it desires, both internally and in
the environment. Both structural and human aspects are important in creating
intelligence in organisations.
There are several human-based factors in organisations that have an effect on
intelligence. Employees have different kinds of intelligence due to their back-
grounds, experiences and abilities. Different actors have, for example, divergent
abilities to observe external events like developments in health problems. Some
experts might emphasise the importance of people’s personal lifestyles, while
others take into consideration the quality of the service system in solving health
problems.
The structures of organisations affect intelligence as well. Wilensky (1967)
made the ground-breaking observation concerning this issue in the 1960s. Due to
their structures, organisations show a similar tendency to believe what they want to
believe, to become the victims of their own slogans and propaganda and to resist or
to silence warning voices that challenge their assumptions. This decreases intelli-
gence in organisations.
Generally speaking, the concept of organisational intelligence can be
approached in two ways. First, intelligence can be based on individual employees’
or professionals’ intelligence. This approach emphasises people’s competence,
skills and talent. Generally, an intelligent person can learn from experience,
understand abstract thought, resolve novel problems and adapt to and manipulate
a given environment (Travica 2015). From this point of view, health policy is
intelligent if individual employees have the ability to solve customers’ problems
and implement health policies purposefully. An organisation’s intelligence is the
sum of its employees’ intelligence. We call this type of intelligence individual
intelligence.
Traditionally, social scientists often make use of variables to describe not only
individual persons but also groups, communities or other collectives. The second
form of intelligence is collective intelligence. Conceptually, it is a phenomenon
where a group of initially independent agents develop a collective approach to
tackle a shared problem, and this is a more powerful approach than any of them
1.4 The Concept of Organisational Intelligence 7

might have developed individually, which can be called collective intelligence

(Heyloghen 2013). Knowledge creation, sharing and use can take place in a
group context (Travica 2015).
On the other hand, organisational intelligence may be invisible and unnoticeable
for people who work in organisations. This is related to the idea presented by
Dreyfus and Dreyfus (1980). According to them, experts have the ability to solve
complex problems, but they do not necessarily know themselves which aspects
their working methods are based on.
Our starting point is therefore not that healthcare organisations do not represent a
high level of intelligence. Actually, if we compare typical healthcare organisations
with any number of organisations in other sectors, they, quite often, stand out as the
most intelligent organisations. The employees are well educated, and the organisa-
tions in the healthcare sector work in very rational ways. In the existing research
literature, healthcare organisations are described using the concept of an expert or
professional organisation. This indicates that healthcare organisations have a lot of
intelligence.
There are several common characteristics in professional organisations. The
following aspects have been used in describing professional organisations (Abbott
1988; Sveiby 1997; Alvesson 1993; Brock 2006). These aspects are typical in
healthcare organisations as well:
• Organisations’ core activities are based on knowledge.
• Knowledge creation is an important aspect in organisations.
• Organisations use employees’ expertise in solving complex problems.
• Organisations have complex structures.
• Outputs are created by the activities in relation to customers.
• A key part of the staff consists of highly educated employees.
• There are a lot of non-material outcomes in organisations (like services).
• Experts have strong autonomy in organisations. Their autonomy covers not only
planning work but operational aspects as well.
• Experts have a lot of power in organisations.
• Professions and their ethical codes have an effect on work in organisations.
Healthcare organisations are typically professional organisations that concen-
trate especially on treatments concerning human health and diseases. Their intelli-
gence is based on the capacity of individual experts, doctors in particular, but,
increasingly, other medical staff too. The actions of healthcare organisations are
based on theoretical knowledge. The key experts often have quite extensive expe-
rience in their respective fields.
Experts’ work is based on the values and ethics of their profession (Sveiby
1997). In practice, healthcare experts are guided by stronger ethics than many other
professions. From this perspective, healthcare organisations are not independent
from their professional community.
Highly educated experts quite often use a language of their own. For example,
doctors would use their professional jargon—medical terms, etc.—which is very
difficult for outsiders to understand. This may have an adverse effect on a
8 1 Introduction

healthcare organisation’s collaboration with other professional organisations or

with service users.
In healthcare, the autonomy of professionals is very high within organisations.
Professionals—for example, doctors—have a lot of control over their work. To a
high extent, this power covers the planning of work as well as operational aspects,
such as decision-making concerning customers. In many organisations, healthcare
experts have a lot of resource power due to their knowledge. They know what kinds
of equipment are needed in successful medical treatment, etc. In practice, it would
be very hard to create coercive healthcare organisations in which, for instance,
‘policy makers had power over professional employees’.
Professionals have an important role in creating, sharing and using knowledge.
To some extent, professional principles have an effect on producing collective
intelligence in healthcare organisations. This is related to collegial practices. For
instance, it is possible that doctors consult each other concerning the treatment of a
patient. Different kinds of collegial meetings at hospitals are another example of
organisational practices that create collective intelligence.
In addition, the various professions are not equal in healthcare organisations.
Doctors, especially, have traditionally had a lot of power and special roles in
healthcare organisations (Freidson 1988). This has created hierarchical structures
and tensions that have an effect on the contents of intelligence.
There are a lot of professional coercive practices in healthcare organisations as
well. Typically, the processes have to be reliable and rational, which is a guarantee
of quality in treatments. People would have defined roles—like in surgeries—in
healthcare practices.
Summing up then, healthcare organisational intelligence is largely determined
by the archetype of a professional organisation. Intelligence is highly personalised
and employees quite often have different job descriptions as experts. Hence,
healthcare organisations have plenty of practices that shape collective intelligence.
Some of them are quite often enabling (like collegiality) practices, but there are
coercive practices (like well-defined processes) as well. If healthcare organisations
represent a high level of intelligence, one may ask: What is the problem? Why is it
still important to think about how to make changes in organisational intelligence?
The problem of healthcare organisations’ intelligence is related to changing
environments. When organisational environments are rapidly changing, how can
organisations sustain the capabilities of adapting to and shaping their environ-
ments? This problem has been addressed by, for instance, the contextually dynamic
capabilities (Teece et al. 1997; Teece 2007). In a constantly changing society, the
starting point is that organisations need the abilities to learn, evolve and adapt more
and more. In this framework, an organisation can maintain a high level of intelli-
gence if it is dynamic and reflective.
Actually, healthcare organisations have been criticised for the fact that they are
not able to implement changes. According to these arguments, healthcare organi-
sations are too rigid. For example, Baker and Denis (2011) have paid attention to
the fact that there is a lot of resistance to changes in hospitals due to institutionalised
habits and beliefs. Traditionally, they act steadily, slowly and predictably in a
1.5 Synthesis 9

changing environment and produce products and services that are based on experts’
standardised working methods. According to Baker and Denis, this is a problem
because hospital environments are facing changes and increasing turbulence. Var-
ious studies have found problems with unchangeable intelligence in the healthcare
sector. Professional communities, for example, have a higher tendency to maintain
the existing order than to make rapid changes. Rigidity is even higher if the changes
are a threat to the hierarchical power relations that, for instance, give doctors the
position of the key profession in healthcare organisations. If there are problems in
customer relationships, healthcare organisations may only react by developing new,
standardised services. This has happened even when the customers’ changing
values have been the main reasons for service delivery. Yet, it is an exaggeration
to claim that healthcare organisations are totally lacking adaptability. For example,
new treatments, medicines and technologies are normal business in healthcare
organisations.
Hence, the main challenge is how to change the framework within which health
organisations try to solve emerging and complex problems in a changing environ-
ment. The intelligent health policy is a comprehensive framework for developing of
healthcare organisations’ management system, activities and services.

1.5 Synthesis

This book is not intended to be a so-called ‘traditional’ book on health policy in

which the authors go through the literature and discussions on health management
and health policy. Our framework of intelligent health policy is based on the
literature of public management, organisation theories and public policy, which
we put into context of health. Our purpose is to describe the present comprehensive
framework for the development of health policy and organisations. In particular, we
have the following four cornerstones in the book: the evolution of well-being,
technology and digitalisation, knowledge-based policy making and service produc-
tion and intelligent management and leadership systems (Fig. 1.1).
First, we emphasise the evolution of the concept of well-being. The intelligent
policy means that we are moving to a more comprehensive understanding about
health. This is related to technology and digitalisation, which are affect healthcare
services. There is more and more co-creation of value, quality and efficiency. The
third cornerstone is intelligent management and leadership of services. The out-
comes are more agile organisation structures, cultures and professions. The last
cornerstone of intelligent health policy includes knowledge-based policy making
and service implementation.
The book consists of eight main chapters. Following this chapter, we continue on
contemporary systemic governance challenges due to the technological revolution.
Harvey points out that technology is defined as the use of natural processes and
things to make products (and services, we would like to add) for human purposes
(2015, pp. 92–93). The twentieth century and the turn of the millennium changed the
10 1 Introduction

INTELLIGENCE IN HEALTH POLICY AND IN HEALTH CARE

ORGANIZATIONS

TECHNOLOGY AND
DIGITALIZATION
More co-creation of
value, quality and
efficiency
THE EVOLUTION KNOWLEDGE-
OF WELL-BEING BASED POLICY
More comprehensive MAKING AND
understanding about SERVICE
health INTELLIGENT IMPLEMENTATION
MANAGEMENT
AND LEADERSHIP
OF SERVICES
More agile organization
structures, cultures and
professions

Fig. 1.1 Main elements in this book

evolution of generic technologies into a totally new era: technological innovations

became big business. Today, the rapidly changing technological context—particu-
larly the progress of robotisation, artificial intelligence, the Internet of Things
(IoT)—has radically altered the kinds of skills that are advantageous to labour,
and educational systems have often lumbered awkwardly to keep up with the new
demands.
Chapter 3 of this book is especially grounded on the newest literature concerning
policy analysis. This chapter broadly discusses current challenges in organising and
running public policies and health policy in particular. In this part of the book, we
argue that there is a lot of talk about complexity in society—but eventually little
evidence about what actually constitutes this complexity and how public policies
deal with the complexity domain. This part of the book deals with what the
promotion of intelligence presupposes from the perspectives of public policy,
decision-making, implementation and evaluation. The starting point is especially
the knowledge management and decision-making procedures at the level of health
policy. This chapter deals with issues such as forecasting and the urgent need to
develop specific ex ante evaluation methods and procedures and underlines putting
an emphasis on forecasting societal and health policy-related problems instead of
ex post trials. Moreover, this chapter analyses the emergence of new information
bases for health policy and the role of big data and the Internet of (Intelligent)
Things in particular.
The topic of Chap. 4 is the conceptual roots of organisational intelligence. This
chapter explores the nature of the intelligence and organisational learning of public
policy and healthcare organisations with regard to both individual organisations and
multiple organisational ecosystems. The main ideas behind modern systems theory
1.5 Synthesis 11

(MST) and the logic developed by MST theorists in the domain of organisational
intelligence are pinpointed in the chapter.
Chapter 5 includes a discussion on organisational knowledge and service users at
the heart of modern organisational intelligence. Knowledge management has
attracted considerable attention in recent years in the fields of public management
and health policies. Nonetheless, there are few widely shared views according to
which the term itself is defined, much less a consensus on how best to apply it in
business. In this chapter, the role of organisational knowledge in the field of health
is scrutinised (by making a distinction, for instance, between the use and exchange
value of information). The chapter discusses how to manage knowledge internally
and externally in order to achieve organisational success in health-related services.
Chapter 6 examines the characteristics of intelligent healthcare organisations
(i.e. the organisation-level forms of intelligence). An intelligent organisation is, for
instance, able to operate interactively, share its expertise, cross professional silos,
learn from mistakes and act adaptively in relation to changes in the operating
environment. This part of the book makes a new interpretation of organisational
theories from the perspective of intelligence with special emphasis on research
concerning the crossing of interfaces. In addition, this part of the book introduces
the concept of the ‘service space’, developed and theorised by the authors for this
book and our earlier publications.
The content of the seventh chapter is intelligent leadership in the field of health.
The chapter sets out to explore debates within the field of leadership studies. The
basic argument is that traditional leadership paradigms do not suffice anymore in
healthcare organisations. Intelligent people–like doctors, nurses and other
healthcare professionals–behave differently. The leader’s role is to point the direc-
tion, act as the coach and develop the personnel. This approach challenges and
confronts the contemporary models of clinical leadership in healthcare in
multiple ways.
Chapter 8 of the book discusses the role of accountability and performance
management within the framework of intelligent health policy. In this chapter, we
discuss first—from the service-systems perspective—how accountabilities differ
from a hierarchic and organisational perspective within the domain of new public
management (NPM) and new public governance (NPG), looking to shed new light
upon accountability as a management topic. This chapter scrutinises the concept of
service systems and their accountabilities, and the role of integrated social and
healthcare services is discussed in particular. This chapter also explores the impli-
cations of this transformation for evaluation, performance monitoring and account-
ability, and it emphasises that horizontal accountability, which references a wide
democratic footprint, is likely to become more explicit. To this end, this chapter
develops the idea of the transformation of public sector performance management
from the viewpoint of organisational intelligence.
The synthesis part of the book draws together the main ideas of the book—theoret-
ically, conceptually and in terms of practice. This part of the book sets out practical and
managerial implications as well—for policy, organisational and service-user level. It
also discusses the landscape of future health policies and asks what is the modus
12 1 Introduction

operandi of public policy after the emergence of organisational intelligence. The

essential purpose of this chapter is to provide everyday actors with insights and ideas
to reform policies and services in the field of health towards the direction of intelligent
organisation.

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Chapter 2
Systemic Governance Challenges
and Well-Being

Abstract This chapter discusses the role of contemporary systemic governance

challenges in society. Of particular interest is the question of how these challenges
affect human health and well-being. By definition, health is a rather difficult
concept since it contains many elements and dimensions. In this chapter, we
argue that today we need a much broader understanding about human well-being
than the ‘mere’ definition of health. Well-being addresses human life more com-
prehensively. Systemic governance challenges, based on the ongoing and pervasive
technology revolution, exist as a result of changes in the quality and quantity of
human beings, the stock of human knowledge particularly as applied to human
command over nature and the institutional framework that defines the deliberate
incentive structure of a society. These changes have an effect on the way we think,
our ability to understand societal problems and our health and well-being. Gover-
nance challenges redefine the role of governance. We suggest that there are
definitely limits for governing because of the complexity of society. Consequently,
this affects how health policies and healthcare organisations operate in local,
regional, national and transnational service spaces—service ecosystems consisting
of public, private and non-governmental healthcare service providers. This also
means that public sector management paradigms transform towards a new frame-
work—a framework in which the role of government is to coordinate, integrate and
set guidelines and meta-level societal objectives. This view holds that the current
public sector management paradigms of the NPM and NPG have not only reached
their maturity but will eventually come to an end. The complexity of society calls
for complex public policies and a new understanding and analysis of the integrative
role of the government. This, in turn, requires the competence to carry out a system-
level redesign of healthcare.

2.1 The Evolution from Health to Well-Being

In this section, our main argument relates to the changes in society, which mainly
occur through digitalisation, and the connections between health and society. Health
and society are definitely linked with each other. Marrot (2015, pp. 42–43) stated not
long ago that there are two definite ways that societies can affect health in multiple
ways—there are two definite variables in society that can affect health in multiple

© Springer International Publishing AG 2018 15

P. Virtanen, J. Stenvall, Intelligent Health Policy,
https://doi.org/10.1007/978-3-319-69596-9_2
16 2 Systemic Governance Challenges and Well-Being

ways. In this chapter, we take the position that the concept of health is a bit
old-fashioned in today’s society. We propose that the concept of well-being would
be a better concept to deploy in the future health policy since it covers more
explicitly the citizens’ subjective views. Health is thus not only a symptom; it is
also a subjective feeling of well-being.
This is because we think it is important to understand that society’s new systemic
governance challenges test digitalisation as a framework for approaching the
question of health as well as the changing context of public policy making in
society. At the heart of these conceptual dimensions is health itself. In the follow-
ing, we ask how the concept of health evolves in a society where governance
challenges are pervasive and vast.
It should be noted that health itself is a problematic, multidimensional and also
controversial concept. The concept of health refers, first, to a narrow medico-
technical definition. Take, for instance, the degree of bodily functioning, which is
a measurable procedure at hospitals. Second, there are descriptions of health in the
framework of generic descriptive systems, which make it possible to measure
health, for instance, in clinical trials and evaluative studies (such as the health-
related quality of life [HRQL] by using the metrics of HRQL).
Finally, we can think of health—as the famous World Health Organization
definition suggests—as a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity. This kind of approach defines
health in a broader perspective by taking into account more aspects in regard to
health than the above-mentioned medico-technical definitions do. What is impor-
tant to notice is that the World Health Organization definition takes a perspective
towards the well-being of individuals and communities, which incorporates the idea
of comprehensive well-being (Evans et al. 2013; Dye et al. 2013; Olsen 2009).
One important aspect is to make a distinction between diagnosed and experien-
tial health. Both of these aspects are relevant since they correlate with each other.
For instance, the health module in the European Union Statistics on Income and
Living Conditions (EU-SILC) survey allows respondents to report on their general
health status, whether they have a chronic illness and whether they are limited in
usual activities because of a health problem. Despite the subjective nature of these
questions, indicators of perceived general health have been found to be a good
predictor of people’s future healthcare use and mortality (DeSalvo et al. 2005; Bond
et al. 2006).
Based on the evolving nature of the concept of health and the discussion related
to combining the government’s role, the objectives of health policy and the means
of implementation in terms of health have emerged gradually during the last years.
Michaelson and Hämäläinen (2014), to take one example, made a substantial
achievement by rethinking the role of health and social deprivation in the current
policy discourse. They suggest that policy makers should consider this question
seriously in the real-world business of public policy making because they most
likely might start to think that a more comprehensive understanding of health is
actually the primary focus of modern societies. The simple reason for this is the fact
that, today, only a gradually decreasing minority of the global population suffer
2.1 The Evolution from Health to Well-Being 17

from material and financial deprivation problems. This is not to deny that the
poverty would not exist but is to make argument that for a majority of global
population, poverty-related questions are not relevant anymore.
The main problem behind the criticism presented by Michaelson and
Hämäläinen (2014) is that the current headlines of health-related policy measures
are outdated because they rest too much on pathogenic paradigms of health,
overemphasise economic models and do not take into account subjective measures
of well-being. Therefore, there is a need for an approach in government priority and
goal setting in health policy that would be anchored in more multidisciplinary
approaches, ideas and practice. Public policies should take a more comprehensive
view of individual- and community-based health and conceive of human beings as
biological, psychological, social, political and economic creatures (Hämäläinen
2014). Then, the crucial question is where to look science-wise if the approach
includes multidisciplinary elements. According to Michaelson and Hämäläinen
(2014), a window of opportunity is open, but it is based on rethinking economic
growth in relation to human happiness, positive psychology and the emerged
contributions of well-being theory (Seligman and Csiksentmihalyi 2000; Seligman
2011; Virtanen and Sinokki 2014).
One might think that happiness and well-being cannot be on government
agendas because it is such a new idea without a long history of conceptual theory
building, and it has never been thought to be included in the government’s tasks.
Just think what the German philosopher Gottfried Wilhelm Leibnitz wrote in his
Codex Juris Gentium over 300 years ago. He claimed that the careful and constant
pursuit of happiness is a natural right of human beings, and this is a right the
government has to protect. The same idea is replicated in the writings of John Locke
and Thomas Jefferson (as cited in Csiksentmihalyi 2014).
To conceive well-being as a policy goal is not without problems, though, far
from it, as Hämäläinen suggests (2014). One of the main problems around the
subject is the measurement aspect or the lack of theory building behind the existing
well-being measures. Hämäläinen (2014) suggests that the key determinants of
well-being in everyday life are composed of five separate dimensions: the environ-
ment; the individual’s capacities and resources, everyday activities and roles and
sense of coherence; and Maslowian needs categories. This combination of funda-
ments is of importance since it incorporates the multidimensional approach towards
well-being. As far as how we read Hämäläinen (2014), the notion of everyday
activity is of special importance since it focusses on individual’s memberships in
several communities and social tribes.
Alongside with well-being, what is also important is the sense of coherence
aspect—based on the famous work by Antonovsky—since it approaches the sub-
jective dimensions of well-being, which constitute the basic elements of happiness
in the everyday life of individuals. This salutogenic approach (see Eriksson and
Lindstr€on 2014) underlines the importance of structured and empowering environ-
ments where people are able not only to satisfy their basic needs and to get access to
health services but are also able to identify their internal and external resources and
to deploy them in order to realise their aspirations, to experience meaningfulness
18 2 Systemic Governance Challenges and Well-Being

and to cope with their lives by taking into account health promotion aspects in the
framework of societal determinants of health.
There are also downsides to well-being, which are also highlighted by
Hämäläinen (2014). They include ‘short-termism’ (individuals’ preferences vary
over time), selfishness (which eradicates socially harmonious and unselfish behav-
iour) and path dependence (individuals’ decisions in certain situations are
predestined by earlier decisions individuals took in the earlier phases of their life’s
course). Path dependence reportedly applies also to health policy (Weissert and
Weissert 2012). This means that policy decisions easily become self-reinforcing:
earlier decisions quite often ‘lock up’ policy options that decision-makers would not
now choose to initiate. This leads to the situation in which future policy decisions
are, in a word, path-dependent on past decisions with regard to health policy.
Our suggestion is that the concept of health evolves towards a more compre-
hensive concept of well-being, and this process will consequently affect policy
making in the field of public policies related to health and well-being issues. What
is important to notice is that the complexity of policy making changes also parallels
changing understanding in regard to health. We do not suggest, however, that health
policies (content-wise) undergo radical re-engineering process. Instead, we stress
that the innovation aspect should be incorporated within the health policy domain
and framework. This means that there is definitely a new agenda for issues related
to well-being in the government agenda. Our assumption is that well-being is, more
or less, transformed from the austerity agenda to a framework, which manifests
health- and well-being-related issues as a mechanism to enhance local-, regional-,
national- and transnational-level competitiveness.
This paradigm shift takes place where systemic governance challenges prevail
and penetrate current societies and all horizontal and vertical levels of public policy
and administration. In the following, we will discuss what these challenges are and
how they affect public policies in terms of planning, implementation and evalua-
tion. Moreover, the changing contents of health (or well-being, for that matter) are
not the only key issues of importance at stake here—it is also interesting to focus on
and scrutinise how the role of policy making and how the government and market
contribute complex policy setting.
Finally, this changing role will seriously affect the traditional way of under-
standing decision-making at the level of public policy, which, as Saltman has
described, is a morally responsible process where decision-makers are ethically
constrained to ‘begin from the Hippocratic premise of “first, do not harm”’ (2015,
p. 23). We argue that not only are moral and ethics important; it is equally (or more
important) to understand modern societies through the lenses of digitalisation and
‘the second machine age’, as Brynjolfsson and McAfee (2014) labelled this phe-
nomenon. Before we can focus on systemic governance challenges, we’ll have to
formulate an understanding about the concept of governance itself. That is where
our story continues from here.
2.2 Elusive Governance 19

2.2 Elusive Governance

Governance is definitely a concept with multiple definitions as well as connotations.

Kuhlmann et al. define the concept simply by describing it as ‘governing without
government’ (2015a, b, pp. 4–5). According to them, the field of health governance
includes qualitatively new dimensions of policy making that attempt to connect
institutional governance (e.g. regulation) and operational governance (e.g. leadership,
management and organisational varieties of coordination, networking and control).
According to Kuhlmann et al. 2015a, b), this definition links the concept of governance
to NPM and to the debates of accountability, performance and leadership.
Kuhlmann et al. (2015a, b) are, of course, right when defining the role of meso-
level governance powers as consisting of a variety of healthcare organisations,
stakeholder institutions and professional actors. What is also important in their
conceptual framework is, in fact, the role of transnationalism and how it has created
multidimensional tensions between local, regional, national and transnational
dimensions of governing. Goodin et al. (2008; see also Young 2008) point out
that there have always been various limits to command and control in the public
policy framework. This causes the government to give way to ‘governance’,
suggesting that governing actually is less and less a matter of ruling by power
and hierarchical authority structures and more and more a matter of negotiating
through a series of various floating alliances and networks.
Governance is fundamental as a framework for complex public policies and
service space constituted by public, private and non-governmental organisations.
Moreover, it is deployable in the framework of open systems as interpreted from the
point of view of MST. Governance can address, to take an example, interdepen-
dencies and network relations of different factors (such as determinants, stake-
holders, institutional actors, settings, reciprocal cooperation and coordination
mechanisms and the power relations in between principals and their subordinate
agents).
In this book, however, we hold the ambitious view that governance relates—as a
phenomenon—both to theories and models. Theoretically, governance refers to a
conceptual framework (what constitutes governing) adapted to the public policy
domain, and, as a model, it is more or less a process (how governing actually is
carried out). With theory, we refer to Giere (1998), who argues that theories are
generalised theoretical hypotheses. This means that justifying a theory is actually
about justifying a theoretical hypothesis or a set of hypotheses. Models, then, in our
analytical dictionary, refer to kinds of conceptual and partly theoretical frame-
works, which help to conceptually understand the topic under scrutiny and also give
guidance to the actual implementation of governing. Popper (1963) calls this a
discovery of axiomatic systems—models, which consist of a set of things, relations,
operations or functions.
Before turning to discussing the emergence of new systemic governance chal-
lenges, it is appropriate to look at different theories and models of governance and
its conceptual framework through interpreting and reinterpreting the contemporary
20 2 Systemic Governance Challenges and Well-Being

management and public policy literature about governance. Governance has played
a pivotal role in the semantic toolbox of public policy and public administration for
decades (Asaduzzaman and Virtanen 2017). In the wise words of Pollitt (2005),
there are certain ‘hardy perennials’ of contemporary public policy and public
management. According to our view, these hardy perennials include conceptual
entities such as bureaucracy, network, decentralisation/centralisation, organisation,
leadership, management, power and governance. The last one of these, governance,
has been an unassailable concept in the management and public policy sciences for
decades now.
As a whole, the concept of governance has thus had a long conceptual history
with multifaceted meanings. Governance has acted as a counterpart of (often
unspoken) alternatives for public sector management, NPG and public sector
leadership. Governance has gained popularity in management sciences and in
academic public policy discourse because of its multivalency—its ability to link
up with many other arguments and theoretical concepts.
Despite the current interest and debates around the concept governance, one
should bear in mind that governance is not a new concept but rather is as old as
civilisation or human history (Farazman 2015). As a concept, governance is incor-
porated with the very long history of governing, rule, authority structures and
domination. Currently, it not only occupies the central stage of development
discourse, but it is also considered as the fundamental component to be incorpo-
rated in the development policy of both developed and developing nations. Despite
its growing importance to researchers, development practitioners, policy makers
and international aid agencies, governance is far from mature as a concept. Rather it
is a dynamic concept and worth examining analytically and systematically
(Asaduzzaman and Virtanen 2017).
Overall, it seems that the term governance is notoriously slippery and for good
reason. But maybe this—the conceptual vagueness of the term—is in fact what
manifests the secret of its success. By definition, however, we would like to
emphasise the trivial starting point that the terms government and governance are
not same. They are not synonymous terms, although both share goal-oriented
objectives, activities (interventions), networking practices and expected
(or unexpected) outcomes.
Government is about legally and formally derived authority and policing power
to execute and implement activities. De Vries (2016, pp. 19–20), for instance,
describes government as a constituting element of a nation-state, which is about
the totality of political and administrative organisations and institutions within that
nation and which is authorised to allocate collectively binding values and ser-
vices—i.e. public values and services. Government, thus, is about bureaucracy,
legislation, financial control, regulation and power, whereas governance refers to
the creation, execution and implementation of activities backed by the shared goals
of citizens and organisations, who may or may not have formal authority or policing
power (Bourgon 2007). Consequently, governance refers more to a growing use of
non-regulatory policy instruments, which focus the attention towards proposed,
2.2 Elusive Governance 21

designed and implemented cooperation by government and non-state actors work-

ing together within the same framework of policy agenda.
By definition, our approach treats governance as a system of multiple govern-
ments, other institutions and organisations working together in the form of formal
and informal networks focusing on strengthening effective and accountable insti-
tutions, democratic principles, electoral processes and representation and respon-
sible structures of government agencies in order to ensure an open and legitimate
relationship between civil society and the state. This definition emphasises the
relationship between civil society and the state, which is a very fundamental aspect
in the origins of the governance concept. This means that this setting differentiates
the study of governance from the study of government. This view holds that the
credibility and legitimacy of government can be achieved effectively and efficiently
through decentralisation, sharing, people’s participation, accountability, transpar-
ency and responsiveness (Asaduzzaman and Virtanen 2017). This definition also
takes pretty much into account how, for instance, the Organisation for Economic
Cooperation and Development (OECD) (1995) defines governance, including pub-
lic administration; the institutions, methods and instruments of governing; the
relationships between the government and citizen (including businesses and other
citizen groupings); and the role of the state.
In terms of health and well-being, governance is an important mechanism in
transforming the objectives of public policies into concrete measures,
transnationally. This is due to the fact that healthcare policy has long been impacted
by actors and governance processes outside of the control of national jurisdictions
and single governments. Ruckert et al. (2015, 37–38, 49–50), to take an example,
argue that, in the wake of neoliberal reform processes during the 1980s and 1990s
by various multilateral organisations, especially international finance institutions
(such as the World Bank and the International Monetary Fund), social and health
policy choices and agendas have been increasingly circumscribed by various
adjustment programmes, which, in turn, have strengthened the role of these inter-
national finance institutions as agenda-setters in terms of global social and
healthcare policies. Ruckert et al. say that this development is not to be treated as
a positive transition, and they suggest that the global ‘health policy community’
should greet the return of these international finance institutions as the principal
crisis fighters with suspicion because of the loss of policy space, commodification
of health systems, austere budget environments and tightening fiscal policies.
To summarise then, we can say that the concept of governance applies to multiple
forms of collective action. However, it is about more strategic aspects of steering a
society: the larger decisions about direction and roles. That is, governance is not only
about where to go but also about who should be involved in deciding and in what
capacity. Therefore, we would like to address five deployment areas where gover-
nance is manifested with special reference to public policy making in the field of
health (on this typology, see Asaduzzaman and Virtanen 2017).
First, governance in global space, or global governance, deals with issues
outside the purview of individual governments, as suggested above with examples
of international finance institutions’ new role in defining the transnational and
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 “It must be because Di has such a vivid imagination,” continued her
sister musingly. “She sees what he might have been, what he probably was
meant to be——”
“And what he would still be,” put in Jellaby, “if only he would allow his
nice wife to influence him a little.”
“But John,” thought I, “in that is right. Let us be fair and admit his good
sides. A wife should never, under any circumstances, be allowed allowed
——”
Then, suddenly struck by the point of view, by the feminine idea
(Socialists have the minds of women) of a man’s being restored to what he
was primarily intended to be when he issued newly-made (as poets and
parsons would say) from the hands of his Maker through the manipulations
of Mrs. Menzies-Legh, my sense of humour played me a nasty trick (for I
would have liked to have heard more) and I found myself bursting into a
loud chuckle.
“What’s that?” exclaimed Jellaby, jumping up.
He soon saw what it was, for I immediately put my head round the edge
of the pillar.
They both stared at me in a strange alarm.
“Pray do not suppose,” I said, smiling reassuringly, “that I am a ghost.”
They stared without a word.
“You look as though I might be.”
They went on staring.
“I could not help, as I sat here, hearing what you were saying.”
They stared as speechless as though they had been caught killing
somebody.
“I really am not a spirit,” said I, getting up. “Look—do I look like one?”
And striking a match I playfully passed it backward and forward across
my features.
But its light at the same time showed me a flush of the most attractive
and vivid crimson on Frau von Eckthum’s face, colouring it from her hair to
her throat. She looked so beautiful like that, she who was ordinarily white,
that immediately lighting another I gazed at her in undisguised admiration.
 “Pardon me,” I said, holding it very near her while her eyes, fixed on
mine, still seemed full of superstitious terror, “pardon me, but I must as a
man and a judge look at you.”
Jellaby, however, unforgivably ill-bred as ever, knocked the match out of
my hand and stamped on it. “Look here, Baron,” he said with unusual heat,
“I am very sorry—as sorry as you like, but you really mustn’t hold matches
in front of somebody’s face.”
“Why sorry, Jellaby?” I inquired mildly, for I was not going to have a
scene. “I do not mind about the match. I have more.”
“Sorry, of course, that you should have heard——”
“Every word, Jellaby,” said I.
“I tell you I’m frightfully sorry—I can’t tell you how sorry——”
“You may be assured,” said I, “that I will be discreet.”
He stared, with a face of stupid surprise.
“Discreet?” said he.
“Discreet, Jellaby. And it may be a relief to you to know,” I continued,
“that I heartily endorse your opinion.”
Jellaby’s mouth dropped open.
“Every word of it.”
Jellaby’s mouth remained open.
“Even the word bounder, which I did not understand but which, I
gathered from your previous remarks, is a very suitable expression.”
Jellaby’s mouth remained open.
I waited a moment, then seeing that it would not shut and that I had
really apparently shattered their nerves beyond readjustment by so suddenly
popping round on them in that ghostly place, I thought it best to change the
subject, promising myself to return to it another time.
So I picked up my hat and stick from the chair I had vacated—Jellaby
peered round the pillar at this piece of furniture with his unshut mouth still
denoting unaccountable shock—bowed, and offered my arm to Frau von
Eckthum.
“It is late,” said I with tender courtliness, “and I observe an official
approaching us with keys. If we do not return to the camp we shall have
your sister setting out, probably on angelic wings”—she started—“in search
of you. Let me, dear lady, conduct you back to her. Nay, nay, you need have
no fears—I really can keep a secret.”
With her eyes fixed on mine, and that strange look of perfect fright in
them, she got up slowly and put her hand on my proffered arm.
I led her away with careful tenderness.
Jellaby, I believe, followed in the distance.
 CHAPTER XX

L IFE is a strange thing, and full of surprises. The day before, you think
you know what will happen on the morrow, and on the morrow you find
you did not. Light as you may the candle of your common sense, and
peer as you may by its shining into the future, if you see anything at all it
turns out to have been, after all, something else. We are surrounded by
tricks, by illusions, by fluidities. Even when the natural world behaves
pretty much as experience has led us to expect, the unnatural world, by
which I mean (and I say it is a fair description) human beings, does nothing
of the sort. My ripe conclusion, carefully weighed and unattackably mellow,
is that all one’s study, all one’s thought, all one’s experience, all one’s
philosophy, lead to this: that you cannot account for anything. Do you, my
friends, interrupt me here with a query? My answer to it is: Wait.
The morning after the occurrences just described I overslept myself, and
on emerging about ten o’clock in search of what I hoped would still be
breakfast I found the table tidily set out, the stove alight, and keeping coffee
warm, ham in slices on a dish, three eggs waiting to be transferred to an
expectant saucepan, and not a single caravaner in sight except Menzies-
Legh.
Him, of course, I now pitied. For to have a treacherous friend, and a
sister-in law of whom you are fond but who in her heart cannot endure you,
to be under the delusion that the one is sincere and the other loving, is to
become a fit object for pity; and since no one can at the same time both pity
and hate, I was not nearly so much annoyed as I otherwise would have been
at finding my glum-faced friend was to keep me company. Annoyed, did I
say? Why, I was not annoyed at all. For though I might pity I was also
secretly amused, and further, the feeling that I now had a little private
understanding with Frau von Eckthum exhilarated me into more than my
usual share of good humour.
He was sitting smoking; and when I appeared, fresh, and rested, and
cheery, round the corner of the Elsa, he not only immediately said good
morning, but added an inquiry as to whether I did not think it a beautiful
day; then he got up, went across to the stove, put the eggs in the saucepan,
and fetched the coffee-pot.
 This was very surprising. I tell you, my friends, the moods of persons
who caravan are as many and as incalculable as the grains of sand on the
seashore. If you doubt it, go and do it. But you cannot reasonably doubt it
after listening to the narrative. Have I not told you in the course of it how
the party’s spirits were up in the skies one hour, and down on the ground the
next; how their gaiety some days at breakfast was childish in its folly, and
their silence on others depressing; how they quoted poetry and played at
Blind Man’s Buff in the morning, and in the afternoon dragged their feet
without speaking through the mud; how they talked far too much
sometimes, and then, when I wished to, would not talk at all; how they were
suddenly polite and attentive, and then as suddenly forgot I could possibly
want anything; how the wet did not damp their hilarity one day, and no
amount of sunshine coax it forth the next? But of all their moods this of
Menzies-Legh’s in the field above Canterbury was the one that surprised me
most.
You see, he was naturally so very glum. True at the beginning there had
been gleams of light but they soon became extinguished. True, also, at
Frogs’ Hole Farm, when demonstrating truths by means of tea in glasses, he
had been for a short while pleasant—only, however, to plunge immediately
and all the deeper into gloom and ill-temper. Gloom and ill-temper was his
normal state; and to see him attending to my wants, doing it with
unmistakable assiduity, actively courteous, was astonishing. I was
astonished. But my breeding enabled me to behave as though it were the
most ordinary thing in the world, and I accepted sugar from him and
allowed him to cut my bread with the blank expression on my face of him
who sees nothing unusual or interesting anywhere, which is, I take it, the
expression of the perfect gentleman. When at length my plate was
surrounded by specimens of all the comforts available, and I had begun to
eat, he sat down again, and leaning his elbow on the table and fixing his
eyes on the city already sweltering in heat and vapour below, resumed his
pipe.
A train puffed out of the station along the line at the bottom of our field,
jerking up slow masses of white steam into the hot, motionless air.
“There goes Jellaby’s train,” said Menzies-Legh.
“Jellaby’s what?” said I, cracking an egg.
“Train,” said he.
 “Why, what has he got to do with trains?” I asked, supposing with the
vagueness of want of interest, that Jellaby, as well as being a Socialist, was
a railway director and kept a particular train as another person would keep a
pet.
“He’s in it,” said Menzies-Legh.
I looked up from my egg at Menzies-Legh’s profile.
“What?” said I.
“In it,” said he. “Obliged to go.”
“What—Jellaby gone? First Lord Sidge, and now Jellaby?”
Naturally I was surprised, for I had heard and noticed nothing of this.
Also the way one after the other left without saying good-bye seemed to me
inconsiderate—at least that: probably more.
“Yes,” said Menzies-Legh. “We are—we are very sorry.”
I could not, however, honestly join in any sorrow over Jellaby, so merely
remarked that the party was shrinking.
“Yes,” said Menzies-Legh, “that’s rather our feeling too.”
“But why has Jellaby——?”
“Oh, well, you know, public man. Parliament. And all that.”
“Does your Parliament reassemble so shortly?”
“Oh, well, soon enough. You have to prepare, you know. Collect your
wits, and that sort of thing.”
“Ah, yes. Jellaby should not leave that to the last minute. But he might,”
I added with a slight frown, “have taken leave of me according to the
customs of good society. Manners are manners, after all is said and done.”
“He was in a great hurry,” said Menzies-Legh.
There was a silence, during which Menzies-Legh smoked and I
breakfasted. Once or twice he cleared his throat as though about to say
something, but when I looked up prepared to listen he continued his pipe
and his staring at the city in the sun below.
“Where are the ladies?” I inquired, when the first edge of my appetite
had been blunted and I had leisure to look about me.
Menzies-Legh shifted his legs, which had been crossed.
“They went to the station with Jellaby to see the last of him,” said he.
“Indeed. All of them?”
 “I believe so.”
Jellaby then, though he could not have the courtesy to say good-bye to
me, could take a prolonged farewell of my wife and of the other members
of our party.
“He is not what we in our country would call a gentleman,” I said, after a
silence during which I finished the third egg and regretted there were no
more.
“Who is not?” asked Menzies-Legh.
“Jellaby. No doubt the term bounder would apply to him quite as well as
to other people.”
Menzies-Legh turned his sallow visage to me. “He’s a great friend of
mine,” he said, the familiar scowl weighing down his eyebrows.
I could not help smiling and shaking my head at that, all I had heard the
night before so very fresh in my memory.
“Ah, my dear sir,” I said, “be careful how you trust your great friends.
Do not give way too lavishly to confidence. Belief in them is all very well,
but it should not go beyond the limits of reason.”
“He’s a great friend of mine,” repeated Menzies-Legh, raising his voice.
“I wish then,” said I, “you would tell me what a bounder is.”
He glowered at me a moment from beneath black brows. Then he said
more quietly:
“I’m not a slang dictionary. Suppose we talk seriously.”
“Certainly,” said I, reaching out for the jam.
He cleared his throat. “I got a lot of letters and telegrams last night,” he
said.
“How did you manage that?” I asked.
“They were waiting for me at the post-office here. I had telegraphed for
them to be forwarded. And I’m afraid—I’m sorry, but it’s inevitable—we
shall have to be off.”
“Off what?” said I, for a few of the more intimate English idioms still
remained for me to master.
“Off,” said he. “Go. Leave this.”
“Oh,” said I. “Well, we are used to that. This tour, my dear sir, is surely
the very essence of what you call being off. Where do we go next? I trust to
a place with trees in it.”
“You don’t understand, Baron. We don’t go anywhere next as far as the
caravans are concerned. My wife and I are obliged to go home.”
I was, of course, surprised. “We are, indeed,” said I, after a moment,
“shrinking rapidly.”
Then the thought of being rid of Mrs. Menzies-Legh and her John and
Jellaby at, so to speak, one swoop, and continuing the tour purged of these
baser elements with the tender lady entirely in our charge, made me unable
to repress a smile of satisfaction.
Menzies-Legh looked in his turn surprised. “I am glad,” he said, “that
you don’t mind.”
“My dear sir,” I said courteously, “of course I mind, and we shall miss
you and your—er—er—” it was difficult on the spur of the moment to find
an adjective, but Frau von Eckthum’s praises of her sister the night before
coming into my mind I popped in the word suggested suggested—“angelic
wife——”
He stared—ungratefully I thought, considering the effort it had been.
“But,” I continued, “you may be very sure we shall take every care of
your sister-in-law, and return her safe and well into your hands on
September the first, which is the date my contract with the owner of the
Elsa expires.”
“I’m afraid,” said he, “I wasn’t clear. We all go. Betti included, and
Jumps and Jane too. I’m very sorry,” he interrupted, as I opened my mouth,
“very sorry indeed that things should have turned out so unexpectedly, but it
is absolutely impossible for us to go on. Out of the question.”
And he set his jaws, and shut his mouth into a mere line of opposition
and finality.
Well, my friends, what do you say to that? What do you think of this
example of the surprises life has in store for one? And, incidentally, what do
you think of human nature? Especially of human nature when it caravans?
And still more especially of human nature that is also English? Not without
reason do our neighbours label the accursèd island perfide Albion. It is true
I am not clear about the Albion, but I am very clear about the perfide.
“Do you mean to tell me,” I said, leaning toward him across the table
and forcing him to meet my gaze, “that your sister-in-law wishes to go with
you?”
“She does,” said he.
“Then, sir——” I began, amazement and indignation struggling together
within me.
“I tell you, Baron,” he interrupted, “we are very sorry things have turned
out like this. My wife is most genuinely distressed. But she too sees the
impossibility—unforeseen complications demand we should go home.”
“Sir——” I again began.
“My dear Baron,” he again interrupted, “it needn’t in the least interfere
with you. Old James will stay with you if you and the Baroness would like
to go on.”
“Sir, I have paid for a month, and have only had a week.”
“Well, go on and finish your month. Nobody is preventing you.”
“But I was persuaded to join the tour on the understanding that it was a
party—that we were all to be together—four weeks together——”
“My dear fellow,” said he (never had I been addressed as that before),
“you talk as if it were a business arrangement, a buying and selling, as if we
were bound by a contract, under agreement——”
“Your sister-in-law inveigled me into it,” I exclaimed, emphasizing what
I said by regular beats on the table with my forefinger, “on the definite
understanding that it was to be a party and she—was—to be—a—member
of it.”
“Pooh, my dear Baron—Betti’s definite understandings. She’s in love,
and when a woman’s that it’s no earthly use——”
“What?” said I, startled for a moment out of all self-possession.
“Well?” he said, looking at me in surprise. “Why not? She’s young. Or
do you consider it improper for widows——”
“Improper? Natural, sir—natural. How long——?”
“Oh, before the tour even started. And propinquity, seeing each other
every day—well,” he finished suddenly, “one mustn’t talk about it, you
know.”
But you, my friends, what do you say to that? What do you think of this
second example of the surprises life has in store for us? I have been in two
minds as to whether I would tell you this one at all, but to a law-abiding
man, calm and objective as I know myself to be and as you by now must
know me too, such an incident though pleasurable could not in any way
affect or alter my conduct. Strictly Menzies-Legh was to be censured for
mentioning it; however that, I suppose, was what Jellaby called the bounder
coming out in him, and I perceived that whatever they exactly may be
bounders have their uses. I repeat, I make no attempt to deny that it was a
pleasurable incident, and although I am aware Storchwerder never liked her
(chiefly, I firmly believe, because she would not ask it to her dinners) I am
convinced that not one of you, my friends, and I say it straight in your
faces, but would have been glad to stand at that moment in my shoes. I did
not forget I was a husband, but you can be a husband and yet remain a man.
I think I behaved very creditably. Only for an instant was there the least
little lapse from complete self-possession. Immediately I became and
remained perfectly calm. Edelgard; duty; my position in life; my beliefs; I
remembered them all. It also occurred to me (but I could not well tell
Menzies-Legh) that having regard to the behaviour throughout the tour of
his wife it was evident these things ran in families. I could not tell him, but
I felt myself inwardly in every way tickled. All I could do, indeed all I did
do, was to say “Strange, strange world,” and get up from my chair because I
found myself unable to continue sitting in it.
“But what do you propose to do?” Menzies-Legh asked, after he had
watched me taking a hasty turn or two up and down in the sun.
“Behave,” said I, stopping in front of him, “as an officer and a
gentleman.”
He stared. Then he got up and said with a touch of impatience—a most
unreliable person as regards temper: “Yes, yes—no doubt. But what shall I
tell old James about your caravan? Are you going on or not? If not, he’ll
pilot it home for you. I’m afraid I must know soon. I haven’t much time. I
must get away to-day.”
“What? To-day?”
“I must. I’m very sorry. Obliged to, you know——”
“And the Ailsa?”
“Oh, that’s all arranged. I telegraphed last night for one of the grooms.
He’ll be down in an hour or two and take charge of it back to Panthers.”
“And the Ilsa?”
“He’ll take that too.”
 “No, my dear sir,” said I firmly. “You leave the Ilsa in our charge—it and
its contents.”
“Eh?” said he.
“It and its contents—human and otherwise.”
“Nonsense, Baron. What on earth would you do with Jane and Jumps?
They’re going up to town with me by train. And my wife and Betti—oh,
yes, by the way, my wife gave me instructions to tell you how very sorry
she was not to be able to say good-bye to you. I assure you she was really
greatly distressed, but she and Betti are motoring up to London and felt they
ought to start as early as possible——”
“But—motoring? You said they had gone to the sta——”
“So they did. They saw Jellaby off, and then were picked up by a motor I
ordered for them last night in the town, and went straight from there——”
I heard no more. He went on speaking, but I heard no more. The series
of surprises had done their work, and I could attend to nothing further. I
believe he continued to express regret and offer advice, but what he said fell
on my ear with the indifferent trickling of water when one is not thirsty. At
first anger, keen resentment, and disappointment surged within me, for why,
I asked myself, did she not say good-bye? I walked up and down on the hot
stubble, my hands deep in my pockets and myself deep in conflicting
emotions, while Menzies-Legh supposing I was listening regretted and
advised, asking myself why she did not say good-bye. Then, gradually, I
could not but see that here was tact, here was delicacy, the right feeling of
the truly feminine woman, and began to admire her all the more because
she had not said it. By degrees composure stole upon me. Reason returned
to my assistance. I could think, arrange, decide. And before Edelgard came
back with the two children, mere heated débris of that which had lately
been so complete, what I had decided with the clear-headed rapidity of the
practical and sensible man was to give up the Elsa, lose my money, and go
home. Home after all is the best place when life begins to wobble; and
home in this case was very near the Eckthum property—I only had to
borrow a vehicle, or even in extremity take a droschke, and there I was.
There too the delightful lady must sooner or later be, and I would at least
see her from time to time, whereas in England among her English relations
she was entirely and hopelessly cut off.
 Thus it was, my friends, that I did not see Frau von Eckthum again. Thus
it was our caravaning came to an untimely end.
You can figure to yourselves what kind of reflections a man inclined to
philosophize would reflect as the reduced party hastily packed, in the heat
and glare of the summer morning, that which they had unpacked a week
previously amid howling winds and hail showers in the yard at Panthers.
Nature then had frowned, but vainly, on our merriment. Nature now was
smiling, equally vainly on our fragments. One brief week; and what had
happened? Rather, I should say, what had not happened?
On the stubble I walked up and down lost in reflection, while Edelgard,
helped (officiously I thought, but I did not care enough to mind) by
Menzies-Legh, stuffed our belongings into bags. She had asked no
questions. If she had I would not have answered them, being little in the
mood as you can imagine to put up with wives. I just told her, on her return
from seeing Jellaby off, of my decision to cross by that night’s boat, and
bade her get our things together. She said nothing, but at once began to
pack. She did not even inquire why we were not going to look at London
first, as we had originally planned. London? Who cared for London? My
mood was not one in which a man bothers about London. With reference to
that city it can best be described by the single monosyllable Tcha.
I will not linger over the packing, or relate how when it was finished
Edelgard indulged in a prolonged farewell (with embraces, if you please) of
the two uninteresting fledglings, in a fervent shaking of both Menzies-
Legh’s hands combined with an invitation—I heard it—to stay with us in
Storchwerder, and the pressing upon old James in a remote corner of
something that looked suspiciously like a portion of her dress-allowance; or
how she then set out by my side for the station steeped in that which we call
Abschiedsstimmung, old James preceding us with our luggage while the
others took care for the last time of the camp; or with what abandonment of
apparent affectionate regret she hung herself out of the train window as we
presently passed along the bottom of the field and waved her handkerchief.
Such rankness of sentiment could only make me shrug my shoulders, filled
as I was by my own absorbing thoughts.
I did glance up, though, and there on the stubble, surrounded by every
sort of litter, stood the three familiar brown vehicles blistering in the sun,
with Menzies-Legh and the fledglings knee-deep in straw and saucepans
and bags and other forlorn discomforts, watching us depart.
Strange how alien the whole thing seemed, how little connection it
seemed to have with me now that the sparkling bubbles (if I may refer to
Frau von Eckthum as bubbles) had disappeared and only the dregs were
left. I could not help feeling glad, as I raised my hat in courteous
acknowledgment of the frantic wavings of the fledglings, that I was finally
out of all the mess.
Menzies-Legh gravely returned my salute; our train rounded a curve;
and camp and caravaners disappeared at once and forever into the
unrecallable past.
 CHAPTER XXI

T HUS our caravaning came to an end.

I could hardly believe it when I thought how at that hour of the day
before I was lying beneath the hop-poles of Frogs’ Hole Farm with the
greater part, as I supposed, of the tour before me; I could hardly believe that
here we were again, Edelgard and I, tête-à-tête in a railway carriage and
with a future of, if I may coin a word, tête-à-têteness stretching
uninterruptedly ahead as far as imagination could be induced to look. And
not only just ordinary tête-à-têteness, but with the complication of one of
the têtes, so to speak, being rankly rebellious and unwifely. How long
would it take, I wondered, glancing at her as she sat in the corner opposite
me, to bring her back to the reason in which she used before we came to
England to take delight?
I glanced at her, and I found she was looking at me; and immediately on
catching my eye she leaned forward and said:
“Otto, what was it you did?”
They were the first words she had spoken to me that day, and very
naturally failing to see any point in them I requested her not to be subtle,
which is courteous for senseless.
“Why,” said she, not heeding this warning, “did the party break up?
What was it you did?”
Were there ever such questions? But I recollected she could not dream
how things really were, and therefore was not as much put out as I would
otherwise have been at the characteristically wifely fashion of at once when
anything seemed to be going wrong attributing it to her husband.
I therefore good-humouredly applied the Aunt Bockhügel remedy to her,
and was willing to leave it at that if she had let me. She, however, preferred
to quarrel. Without the least attempt to change the Bockhügel face she said,
“My dear Otto—poor Aunt Bockhügel. Won’t we leave her in peace? But
tell me what it was you did.”
Then I became vexed, for really the assumption of superiority, of the
right to criticize and blame, went further than a reasonable man can permit.
What I said as we journeyed up to London I will not here repeat; it has been
said before and will be said often enough again so long as husbands have to
have wives: but how about the responsibility resting on the wives? I
remembered the cheerful mood I had been in on getting up, and felt no
small degree of resentment at the manner in which my wife was trying to
wipe it out. Give me a chance, and I am the kindest of men; take away my
chance, and what can I do?
And so, my friends, as it were with a wrangle ended our sojourn on
British soil. I lay down my pen, and become lost in many reflections as I
think of all these things. Long ago have we settled down again to our
ordinary Storchwerder life, with an Emilie instead of a Clothilde in the
kitchen. Long ago we paid our calls announcing to our large circle that we
were back. We have taken up the threads of duty, we have resumed
regulated existence; and gradually as the weeks melt into months and the
influence of Storchwerder presses more heavily upon her, I have observed
that my wife shows an increasing tendency once more to find her level. I
need not have worried; I need not have wondered how I could bring her to
reason. Storchwerder is doing it. Its atmosphere and associations are very
potent. They are being, I am thankful to say, too strong for Edelgard. After
a few preliminary convulsions she began to cook my meals and look after
my welfare as dutifully as before, and other effects no doubt will follow. At
present she is more silent than before the tour, and does not laugh as readily
as she used when I chance to be in a jesting mood; also at times a British
microbe that has escaped the vigilance of those beneficent little creatures
Science tells us are in our blood on the alert to devour intrusive foreigners
crops up and causes her to comment on my sayings and doings rather à la
Mrs. Menzies-Legh, but I frown her down or apply the Aunt Bockhügel,
and in another few months I trust all will be exactly as it used to be. I
myself am exactly as I used to be—a plain, outspoken, patriotic, Christian
gentleman, going steadily along the path of duty, neither looking to the right
nor to the left (if I did I should not see Frau von Eckthum for she is still in
England), and using my humble abilities to do what I can for the glory of
my country and my Emperor.
And now having finished the narrative there is nothing more to do but to
buy a red pencil and put marks on it. Many, I fear, will be those marks.
Unfortunate is the fact that you cannot be sincere without at the same time
being indiscreet. But I trust that what remains will be treated by my hearers
with the indulgence due to a man who has only been desirous of telling the
whole truth, or in other words (and which amount, I take it, to precisely the
same thing) of concealing nothing.
 POST SCRIPTUM

A TERRIBLE thing has happened.

Finished a week ago and the invitations to come and listen already
in the post, with the flat being cleaned in preparation and beer and
sandwiches almost, as it were, on the threshold, I have been obliged to take
my manuscript once more out of the locked drawer which conceals it from
Edelgard’s eyes in order to record a most lamentable occurrence.
My wife received a letter this morning from Mrs. Menzies-Legh
informing her that Frau von Eckthum is about to be married to Jellaby.
No words can express the shock this has given me. No words can
express my horror at such a union. Left to herself, helpless in the clutches
of her English relatives, the gentle creature’s very virtues—her pliability,
her tender womanliness—have become the means of bringing about the
catastrophe. She was influenced, persuaded, a prey. It is six months since
she was handed over entirely to the Menzies-Leghs, six months of no doubt
steady resistance, ending probably in her health breaking down and in her
giving in. It hardly bears thinking of. A Briton. A Socialist. A man in
flannel. No family. No money. And the most terrible opinions. My shock
and horror are so great, so profound, that I have cancelled the invitations
and will lock this up perhaps forever, certainly for some weeks; for how
could I possibly read aloud the story of our harmonious and delightful
intercourse with the tragic sequel public knowledge?
And my wife, when she read the letter at breakfast, clapped her hands
and cried, “Isn’t it splendid—oh, Otto, aren’t you glad?”

THE END

Typographical errors corrected by the etext transcriber:

It it had not been=> If it had not been {pg 7}
though her concience=> though her conscience {pg 133}
the Menzies-Leigh couple=> the Menzies-Legh couple {pg
176}
all enioying themselves=> all enjoying themselves {pg 198}
Mrs. Menzies-Leigh=> Mrs. Menzies-Legh {pg 213}
devasting microbe=> devastating microbe {pg 340}
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